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Forms and Notices

 

 

Document

Purpose

Timeline

Completed by

Sent to

Time of Hire Pamphlet

Notifies new employees about California Workers’ Compensation rights and benefits.  Ensures employees know what to do in case of workplace injury.

Either at the time of hire or by the end of the first pay period

  NA

         NA

Workers’ Compensation Poster

Outlines employee benefits under Workers’ compensation

   NA

 NA

        NA

Personal Physician Pre-Designation Form

Allows an employee to pre-designate a personal physician for treatment of work-related injuries or illnesses

   NA

The employee and the doctor.  Primary Treating Physician must agree.

        NA

SU-17

To be completed for any on campus injury, illness, accident or exposure involving a Stanford University employee or working student.

 

**Except for incidents related to stress or mental health**

To be completed within 24 hours

Supervisor & Injured Worker

"SECURE: Email to Risk Management at: incidentreport@stanford.edu or workerscomp@stanford.edu".

 

SU-17B

It is to be completed for any on campus injury, illness, accident or exposure involving a person other than a Stanford employee.

To be completed within 24 hours

Involved Party &/or University Contact

"SECURE: Email to Risk Management at: incidentreport@stanford.edu or workerscomp@stanford.edu".

State Form DWC-1

This form notifies employees of their right to file a Workers’ compensation claim. They may file by completing and signing the form.

To be provided to the employee within 24 hours or one working day of notice or knowledge of injury

Supervisor or Department Administrator per first page instruction sheet. Employee completes and signs only if filing a claim.

"SECURE: Email to Risk Management at: incidentreport@stanford.edu or workerscomp@stanford.edu".

 

CAL OSHA 5020

Completed (must be typed) when one or more workdays are lost or when treatment is provided in a medical facility.

Submitted to Risk Management within 48 hours

Supervisor, HR, or  department Administrator (Not  completed by the employee)

"SECURE: Email to Risk Management at: incidentreport@stanford.edu or workerscomp@stanford.edu".